Utilization Management Review Nurse

Title: Clinical Analyst (MCG tools and UM platforms)

Location: 1800 Yankee Doodle Road, Eagan, MN 55121

Hybrid 2days per week OR Remote

Duration: 12+ months contract

Clinical Business Analyst

The Clinical Analyst is responsible for leading the design, documentation, configuration, testing, training, and ongoing support of prior authorization (PA) automation solutions using MCG clinical decision support tools and Utilization Management (UM) platforms. This role serves as a key liaison between clinical, operational, and technical stakeholders to ensure automated PA workflows align with evidence-based guidelines, regulatory requirements, and business objectives.

The ideal candidate brings deep expertise in clinical utilization management, payer operations, and healthcare IT systems, with a proven ability to translate complex clinical and regulatory requirements into scalable, automated solutions.

Key Responsibilities

Prior Authorization & UM Automation

• Lead end-to-end analysis and implementation of prior authorization automation across MCG tools and UM platforms
• Design and document automated PA workflows, decision logic, and exception handling aligned with clinical guidelines and payer policies
• Configure MCG guidelines, rules, and integrations to support automated and semi-automated authorization decisions
• Partner with UM operations to optimize workflows, reduce manual review, and improve turnaround times

Business Analysis & Solution Design

• Elicit, analyze, and document business, clinical, and functional requirements
• Translate requirements into detailed functional specifications, user stories, and process flows
• Ensure traceability between business requirements, system configuration, and testing outcomes
• Support solution design decisions with data, operational insights, and clinical best practices

Testing & Quality Assurance

• Develop and execute test strategies, test cases, and validation plans for PA automation
• Coordinate and support unit, integration, UAT, and regression testing
• Validate clinical accuracy, compliance, and operational readiness prior to production release

Training, Deployment & Support

• Create training materials and deliver training for UM nurses, providers, and operational staff
• Support go-live activities and provide post-implementation stabilization and optimization
• Act as a subject matter expert (SME) for PA automation issues, enhancements, and defect resolution

Stakeholder Collaboration & Governance

• Collaborate with clinical leadership, UM operations, IT, vendors, and compliance teams
• Ensure solutions comply with CMS, NCQA, state regulations, and payer policies
• Support audit readiness and documentation related to prior authorization decisions

Required Qualifications

• Bachelor s degree in Healthcare, Nursing, Health Informatics, Business, or a related field (or equivalent experience)
• 5+ years of experience as a Business Analyst in healthcare, payer operations, or health IT
• Strong hands-on experience with MCG (formerly Milliman Care Guidelines)
• Proven experience with Utilization Management and Prior Authorization workflows
• Demonstrated experience designing or supporting clinical decision support or automation solutions
• Strong documentation skills, including requirements, workflows, and test artifacts
• Experience working in Agile, hybrid, or waterfall delivery environments

Preferred Qualifications

• Clinical background (e.g., RN, LPN, MD, PharmD) or significant clinical workflow experience
• Experience with UM platforms (e.g., Predictal, Helios, GuidingCare, TruCare, Epic UM, or similar)
• Experience integrating PA systems with EDI, APIs, or provider portals
• Experience with Jira

Core Competencies

• Clinical and operational understanding of utilization management
• Expertise in prior authorization policy interpretation and automation
• Strong analytical and problem-solving skills
• Excellent written and verbal communication
• Ability to influence without authority and manage complex stakeholder relationships
• Detail-oriented with a focus on quality, compliance, and patient impact

Working Conditions

• Hybrid, local to Twin Cities, ability to work onsite 2 days per week
• May require participation in go-live or production support outside normal business hours